Unusual Blistering

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Hi Pods,
Can you help me out with this one please?

Middle aged lady with a 2 month history of blisters occurring on apex OR distally on plantar surface of 1st or 2nd toes bilaterally. (pt sent me some photos attached; unfortunately photos are not very clear but will give you some idea)

-No Significant medical history
-No medication
-Nil allergies known
-Very early stage of HAV bilaterally
-Active lady that walks 1hr /day (outdoors and/or treadmill)
-Does not perspire much
-Pt is well otherwise

She indicated to me that she tried various blister tapes and has bought new shoes however new blisters appear once old ones are healed.

On viewing her gait (3 weeks ago)I did notice that all digits plantarflexed strongly for ground purchase. Also due to slight hallux deviation, medial aspect of 1st IP joint was subject to alot of pressure during propulsion.

Apart from all the general blister prevention info such as prevent moisture build up, taping and footwear recommendations it was obvious to me that I should attend to the high amount of distal pressure that the 1st and 2nd toes were subjected to. Therefore I made ONE soft foam type pad and ONE otoform pad to distribute pressure proximally to that of the blister sites.

The result was that the original blisters healed well but new blisters formed under both types of padding I made.

Now my question is?
1) Has anyone dealt specifically with similar cases before?
(I tried to think laterally and more systemically as this sudden onset seems peculiar to me.)

Thanks All,
Con

 

Just previewed photos (gee sorry they are really hopeless)

 

Hi,

the images are really difficult to see anything.

Most blistering, that i have come across, have a direct correlation to stress in that area.

I would look at the mobility of the foot. Hypermobile? Does the Pt have a hallux limitus?
Are they a 'heavy' walker, ie driving their feet into the ground when they walk?

The stress could be biomechancial, footwear - shoes and socks.


Remove the stress - remove the blistering
(save the cheer leader - save the world --- Heros)

AD

 

Thanks AD for reply,

As my 1st post indicates I also believe taking away pressure and friction as well as eliminating environment conducive to blistering (such as moisture) are the first steps in preventing blistering.

However, this case 'feels' different.
-The sudden onset
-No lifestyle or footwear change
-Blistering more than one site (not as if just one area has alot of "stress" on it)
-once blistering occurred, changes made to footwear and also paddings provided with little result

I am sure once I refine pressure distributing padding that we will be able to prevent further blistering however I am mystified how this may occur.

There has been recent (2-3months) emotional trauma in her life as her parents passed away (1 month apart). Surely there is no correlation OR could there??

Cheers
Con

 

Where the pressure points are on the photo l can see make it look like the shoe is to short for her foot, but you have stated she changed shoes with no relief and l am sure you checked them yourself also.

It looks like your client might just well be stepping out her gait too much causing the blister at the distal point, this may well be the change in her gait whilst on the tread mill? some people try to push the tread mill along whilst holding the side rails, punishment ?
Can l suggest she stops using the tread mill for a couple of weeks and see the results then?

 

Hi conp,

looks like it could be mechanical in origin.

Whats the nails like?? is she cutting them to short, could be exacerbating the problem.

the medial sulcus looks inflamed as well?? could be the photography.

Good luck

 

Thanks David and bkelly11 for your replies.

David, your advice re treadmill walking is noted and valued. thanks.

bkelly11, thanks for response. I will check nail length closer next time but I think inflammation on medial sulcus is due to strong plantarflexion of digits 'driving' nail into tissue below.

I will let you know how I go HOWEVER if anyone gets a patient with sudden onset of blistering in more than one location WITHOUT and relevant changes (lifestyle, footwear etc) please let me know.

Regards
Con

 

Hi conp
Have you looked at differential diagnosis beyond mechanical-ie systemic? I have had a patient with diabetic bullae- intradermal, rapid onset.
Another patient had pemphigus,although that was certainly more predominant on the other parts of his body.
With the history of your lady, it could be pompholyx- or indeed epidermolysis bullosa.

Just food for thought

regards
cornmerchant

 

Dyshidrosis, a type of eczema due to the Id reaction. She probly has a candida in the gut infestation, or a lurking yeast. There is a webgroup at yahoogroups with great fotos. The salient point is that the blisters reoccur as the first heal. It's very common on hands too. The drug you need is 'Toctino'. Not available in the US. Oral anti fungals like lamisal have success too.

 

It certainly sounds mechanical. There could be a fungal component on top of the mechanica.

The flexor digitorum longus (FDL) is the second best supinator of the STJ. Check Posterior tibial strength as someone with post tib weakness could compenste by using the FDL to try and supinate the STJ. This could explain the gripping in gait.

Another thing that would cause gripping with the flexor hallucis longus (FHL) is a painful first met head. The tendon of the FHL is connected to the more medial slips of the FDL by the master knot of Henry. Most people, when seated, when they try to plantarflex their hallux IPJ will also plantar flex their 2nd and sometimes third toes. When the FHL contracts it decreases the force on the first met head as it increases the force on the hallux. That is why a painful first met head would induce the person to use FHL more. Development of a hallux hammer toe may also occur with high use of FHL.

Cheers,

Eric